Suggested functional level classifications
0 Completely independent
1 Requires use of equipment or device
2 Requires help from another person for assistance, supervision, or teaching
3 Requires help from another person and equipment device
4 Dependent—does not participate in activity

1. Screen for mobility skills in the following order:
(1) bed mobility;
(2) supported and unsupported sitting;
(3) transition movements such as sit to stand, sitting down, and transfers; and
(4) standing and walking activities. Use a physical activity tool if available to evaluate mobility.Screening mobility skills helps provide baselines of performance that
can guide mobility-enhancement programming and allows nursing staff to
integrate movement and practice opportunities into daily routines and
regular and customary care. There are many tools available to measure
physical activity; selection of the appropriate tool depends on the
setting and situation (Halfmann, Keller, Allison, 1997).

2. Observe client for cause of impaired mobility. Determine whether cause is physical or psychological.Some clients choose not to move because of psychological factors such
as an inability to cope or depression. See interventions for Ineffective Coping or Hopelessness.

3. Monitor and record client's ability to tolerate activity and use all
four extremities; note pulse rate, blood pressure, dyspnea, and skin
color before and after activity. See care plan for Activity intolerance.

4. Before activity observe for and, if possible, treat pain. Ensure that client is not oversedated.Pain limits mobility and is often exacerbated by movement.

5. Consult with physical therapist for further evaluation, strength training, gait training, and development of a mobility plan.Techniques such as gait training, strength training, and exercise to
improve balance and coordination can be very helpful for rehabilitating
clients (Tempkin, Tempkin, Goodman, 1997).

6. Obtain any assistive devices needed for activity, such as walking
belts, walkers, canes, crutches, or wheelchairs, before the activity
begins.Assistive devices can help increase mobility.

Chin-ups and pull-ups using a trapeze in bed (may be contraindicated in clients with cardiac conditions)

Strengthening exercises such as gluteal or quadriceps sitting exercises

These exercises help reverse weakening and atrophy of muscles.

9. Help client achieve mobility and start walking as soon as possible if not contraindicated.The longer a client is immobile, the longer it takes to regain
strength, balance, and coordination (Bolander, 1994). A study has shown
that bed rest for primary treatment of medical conditions or after
healthcare procedures is associated with worse outcomes than early
mobilization (Allen, Glasziou, Del Mar, 1999).

10. Use a walking belt when ambulating the client.The client can walk independently with a walking belt, but the nurse can rapidly ensure safety if the knees buckle.

12. Increase independence in ADLs and discourage helplessness as client gets stronger.Providing unnecessary assistance with transfers and bathing
activities may promote dependence and a loss of mobility (Mobily,
Kelley, 1991).

13. If client does not feed or groom self, sit side-by-side with client,
put your hand over client's hand, support client's elbow with your
other hand, and help client feed self; use the same technique to help
client comb hair.This feeding technique increases client mobility, range of motion,
and independence, and clients often eat more food (Pedretti, 1996).

Geriatric

1. Help the mostly immobile client achieve mobility as soon as possible, depending on physical condition.In the elderly, mobility impairment can predict increased mortality
and dependence; however, this can be prevented by physical exercise
(Hirvensalo, Rantanen, Heikkinen, 2000).

2. For a client who is mostly immobile, minimize cardiovascular
deconditioning by positioning client as close to the upright position as
possible several times daily.The hazards of bed rest in the elderly are multiple, serious, quick
to develop, and slow to reverse. Deconditioning of the cardiovascular
system occurs within days and involves fluid shifts, fluid loss,
decreased cardiac output, decreased peak oxygen uptake, and increased
resting heart rate (Resnick, 1998).

3. If client is mostly immobile, encourage him or her to attend a
low-intensity aerobic chair exercise class that includes stretching and
strengthening chair exercises.Chair exercises have been shown to increase flexibility and balance (Mills, 1994).

4. Initiate a walking program in which client walks with or without help every day as part of daily routine.Walking programs have been shown to be effective in improving
ambulatory status and decreasing disability and the number of falls in
the elderly (Koroknay et al, 1995).

6. Watch for orthostatic hypotension when mobilizing elderly clients. If
relevant, have client flex and extend feet several times after sitting
up, then stand up slowly with someone watching.Orthostatic hypotension as a result of cardiovascular system changes,
chronic diseases, and medication effects is common in the elderly
(Matteson, McConnell, Linton, 1997).

7. Be very careful when getting a mostly immobile client up. Be sure to
lock the bed and wheelchair and have sufficient personnel to protect
client from falls.The most important preventative measure to reduce the risk of
injurious falls for nonambulatory residents involves increasing safety
measures while transferring, including careful locking of equipment such
as wheelchairs and beds before moves (Thapa et al, 1996). Elderly
clients most commonly sustain the most serious injuries when they fall.

8. Help clients assume the prone position three times per week for 20
minutes each time. If clients are unable to do so, help them turn
partially over and assume the position gradually.The prone position helps prevent hip deformities that can interfere
with balance and walking. This position may be contraindicated in some
clients, such as morbidly obese clients, respiratory or cardiac clients
who cannot lie flat, and neurological clients.

10. Use gestures and nonverbal cues when helping clients move if they
are anxious or have difficulty understanding and following verbal
instructions.Nonverbal gestures are part of a universal language that can be
understood when the client is having difficulty with communication.

11. Recognize that wheelchairs are not a good mobility device and often serve as a mobility restraint.Wheelchairs can be very effective restraints. In one study, only 4%
of residents in wheelchairs were observed to propel them independently;
only 45% could propel them, even with cues and prompts; no residents
could unlock them without help; the wheelchairs were not fitted to
residents; and residents were not trained in propulsion (Simmons et al,
1995).

12. Ensure that chairs fit clients. Chair seat should be 3 inches above
the height of the knee. Provide a raised toilet seat if needed.Raising the height of a chair can dramatically improve the ability of
many older clients to stand up. Low, deep, soft seats with armrests
that are far apart reduce a person's ability to get up and down without
help.

13. If client is mainly immobile, provide opportunities for
socialization and sensory stimulation (e.g., television and visits). See
Deficient Diversional activity.Immobility and a lack of social support and sensory input may result
in confusion or depression in the elderly (Mobily, Kelley, 1991). See
interventions for Acute Confusion or Hopelessness as appropriate.

Home Care Interventions

1. Assess home environment for factors that create barriers to physical
mobility. Refer to occupational therapy services if needed to assist
client in restructuring home and daily living patterns.

2. Refer to home health aide services to support client and family
through changing levels of mobility. Reinforce need to promote
independence in mobility as tolerated.Providing unnecessary assistance with transfers and bathing
activities may promote dependence and a loss of mobility (Mobily,
Kelley, 1991).

3. Assess skin condition at every visit. Establish a skin care program that enhances circulation and maximizes position changes.Impaired mobility decreases circulation to dependent areas. Decreased
circulation and shearing place the client at risk for skin breakdown.

4. Provide support to client and family/caregivers during long-term impaired mobility.Long-term impaired mobility may necessitate role changes within the family and precipitate caregiver stress (see care plan for Caregiver role strain).

Client/Family Teaching

1. Teach client to get out of bed slowly when transferring from the bed to the chair.

2. Teach client relaxation techniques to use during activity.

3. Teach client to use assistive devices such as a cane, a walker, or crutches to increase mobility.

4. Teach family members and caregivers to work with clients during
self-care activities such as eating, bathing, grooming, dressing, and
transferring rather than having client be a passive recipient of care.Maintaining as much independence as possible helps maintain mobility skills (Lipson, Braun, 1993).

5. Develop a series of contracts with mutually agreed on goals of
increased activity. Include measurable landmarks of progress,
consequences for meeting or not meeting goals, and evaluation dates.
Sign the contracts with the client.Using a series of evolving contracts to modify behavior toward
increasing activity, help the client learn skills to change behavior
(Boehm, 1992).